OBJECTIVE:To characterise contemporary practice patterns in female radical cystectomy (RC) across the UK and Ireland, focusing on preoperative counselling, operative strategies, and postoperative care. SUBJECTS AND METHODS:A 36-item survey was distributed to consultant urologists performing RC, identified via the British Association of Urological Surgeons (BAUS) and Cancer Alliances. The questionnaire addressed surgeon demographics, preoperative assessment and counselling, operative decision-making including organ- and nerve-sparing techniques, and survivorship care. Responses were analysed descriptively; group comparisons were made using the Wilcoxon rank-sum and Fisher's exact tests. RESULTS:A total of 64 surgeons responded (56.1% [64/114]), representing 41 cystectomy centres (70.7% [41/58]). Preoperative assessment of sexual activity (68.8%) and menopausal status (78.1%) was common, whereas sexual orientation (15.6%) and prolapse (26.6%) were rarely addressed. Female surgeons were significantly more likely to enquire about menopausal status (P = 0.025). Counselling on sexual dysfunction (98.4%) and vaginal shortening (96.9%) was routine, but other complications, including prolapse (68.8%), menopause (82.8%), or fistula (6.3%), were inconsistently discussed. Organ-sparing practice varied: 28.1% rarely or never performed organ preservation, citing oncological concerns. High-volume centres were more likely to offer organ-sparing RC (P = 0.013). Over half reported inadequate access to female-specific rehabilitation services, with most centres lacking formal pathways for vaginal complications. CONCLUSIONS:Female RC practice across the UK and Ireland is heterogeneous, with clear gaps in preoperative counselling, uptake of organ-sparing techniques, and survivorship care. There is an urgent need for standardised, evidence-based pathways and consensus guidance to optimise outcomes for female patients.

Context and objective The 2026 European Association of Urology and American Society of Clinical Oncology (EAU-ASCO) guideline update reflects significant developments in the diagnosis and management of penile cancer. This review summarises the key changes and contrasts them with previous recommendations, with particular focus on staging, treatment, quality of life and emerging personalised approaches. Evidence Acquisition The summary is based on a critical appraisal of the full 2026 guideline and its underpinning systematic reviews, with comparison to earlier versions. Recommendations were informed by structured literature assessment and expert panel consensus, incorporating evaluation of benefits and harms, evidence uncertainty and patient values. Evidence Synthesis Major updates include refined pathological risk stratification, routine ultrasound (US)-guided nodal assessment, and broader guidance on organ-preserving surgery. There is support for selective genomic testing and clearer, restructured algorithms are introduced, including newly developed flow diagrams for nodal management, alongside an expanded evidence base for systemic therapy. Greater emphasis is placed on survivorship, centralisation of care and rationalisation of follow-up. However, many recommendations remain informed by retrospective data and expert consensus, reflecting the rarity of the disease and limited prospective evidence. Conclusions The updated guideline promotes more nuanced selection of organ-preserving strategies, earlier detection of regional lymphatic disease, and holistic palliative care, while reinforcing the central role of shared decision-making. Patient summary The new guidance for penile cancer aims to improve care, personalise treatment and better address quality of life, while acknowledging that further research is still needed.

OBJECTIVES:To evaluate the incidence of venous thromboembolism (VTE) after penile cancer surgery using national hospital data and to assess current thromboprophylaxis practices across UK specialist centres. SUBJECTS/PATIENTS AND METHODS:A retrospective cohort study was conducted using Secondary Uses Service (SUS) data on penile cancer surgeries performed in NHS hospitals in England between 2015 and 2024. A national survey of UK Penile Cancer Network (UK PeCaN) surgeons was undertaken to assess current thromboprophylaxis practice. The primary outcome was symptomatic VTE within 180 days of surgery, identified using International Classification of Diseases, 10th Revision (ICD-10) codes. Cumulative incidence of first postoperative VTE was analysed using patient-level time-to-event methods, with censoring at second surgery, 180 days or administrative end of follow-up. Survey responses were summarised using descriptive statistics. RESULTS:In this observational population-level study, 4310 patients underwent 5903 penile cancer-related procedures. A total of 143 VTE episodes were recorded over the 9-year period, corresponding to an overall crude incidence of 2.5%. In patient-level time-to-event analysis, the cumulative incidence of first postoperative symptomatic VTE was 0.21% at 30 days, 0.69% at 90 days and 1.08% at 180 days. Descriptive procedure-level analyses suggested higher unadjusted VTE rates following more extensive procedures, including lymph node dissection and total penectomy, although these estimates should be interpreted cautiously because of staged procedures and unmeasured patient-level confounding. Most VTE events occurred after hospital discharge. The survey, comprising 24 responses from 10 specialist centres, revealed substantial variation in thromboprophylaxis practice, with 71% of surgeons not using formal VTE risk assessment tools. CONCLUSIONS:Venous thromboembolism is an important postoperative complication after penile cancer surgery, particularly after more extensive procedures and staged treatment pathways. Current prophylaxis practices are inconsistent. These findings support the further collection and analysis of disease-specific and the development of procedure-specific guidelines recommending extended thromboprophylaxis in high-risk patients.

OBJECTIVES:To assess local recurrence (LR) and its impact on cancer-specific survival (CSS) in an international multicentric homogeneous cohort of lower-risk patients with penile squamous cell carcinoma (PSCC) that underwent glans-sparing surgery (GSS). PATIENTS AND METHODS:We retrospectively studied patients with PSCC treated with circumcision, wide local excision, glans resurfacing, partial glansectomy and laser ablation, collectively defined as GSS. To understand whether LR itself impacts CSS, patients with lymphatic or systemic disease prior or concurrent with LR were excluded. Predictors of LR and its impact on CSS were assessed using Cox proportional hazard regression and Kaplan-Meier survival analysis, respectively. RESULTS:Across 15 institutions, 550 patients were included. The majority had pathological T1 stage (79%) tumours, reflecting the selection of less invasive tumours for GSS. At a median (interquartile range) follow-up of 41 (23-63) months, 162 (29%) patients experienced LR. LR did not affect cancer-specific mortality and 5-year CSS remained at 99%. Three patients died from penile cancer, none of whom showed a LR during their disease course. The presence of penile intraepithelial neoplasia in the surgical margin was an independent predictor of LR (hazard ratio 2.28, P = 0.02), even after adjusting for additional treatments. CONCLUSION:Patients undergoing GSS for PSCC demonstrate excellent survival outcomes, despite LR in 29% of men. These findings support the use of GSS as a safe and effective treatment option for patients committed to adequate follow-up.

BACKGROUND:Dynamic sentinel node biopsy (DSNB) is the currently preferred staging method of high-risk penile cancer (PeCa) patients with cN0 disease. Recently, there have been advancements in the surgical approach and techniques. This study aims to compare the contemporary DSNB practice and techniques amongst European referral centers. MATERIALS AND METHODS:An online survey was sent to members of the EAU YAU Penile and Testis Cancer working group. These questions delved into various facets of DSNB, encompassing imaging techniques, tracers, surgical approaches, and postoperative patient care. Participating centers were also required to provide video-recorded DSNB procedures in a standardized manner for a comparative analysis of technical nuances. RESULTS:Responses were received from twelve Urologists from nine European centers. Overall, 83% and 42% of surgeons performed >10 and >50 DSNB procedures per year, respectively. There is a broad consensus on the technique and site of tracer injections. Conversely, 50% of centers use lymphoscintigraphy, 17% use SPECT/CT, while 33% utilize both imaging modalities. The predominant choice of dye is Patent V/blue, but 25% of centers use Indocyanine Green (ICG). Notable variability exists in surgical incision sites and lymphatic ligation techniques. The consensus is leaning towards not leaving a wound drain. Overall, 83% of centers adopt antibiotic surgical prophylaxis, with 83% discontinuing it postoperatively. A quarter of centers would advocate for patients to be discharged with thromboprophylaxis, either using low molecular weight heparin or thromboembolic deterrent stockings. On average, the postoperative length of stay in hospital is 1 day. CONCLUSIONS:Variation exists in procedural aspects and postoperative management among centers performing DSNB for PeCa. Newer technologies like fluorescence imaging and SPECT/CT are used in some European centers, but high-quality evidence is sparse, highlighting the need for extensive multicenter research into surgical outcomes and emerging technologies.

Penile cancer is a rare cancer, where patients not only need to deal with the anxiety around a cancer diagnosis, but also manage the consequences of treatment on their self-esteem, body image, and intimate relationships. Many find it embarrassing and difficult to talk to family and friends. Due to this, changes in urination and other physical effects of treatment, many will withdraw from social activities too. Patients need psychosocial support and more needs to be done to address this unmet need. Holistic and multidisciplinary approaches in clinic, with access to counseling, may help patients adjust to their new situation.

Introduction The European Association of Urology (EAU) and the American Society of Clinical Oncology (ASCO) recently issued updated guidelines on penile cancer, emphasising dynamic sentinel node biopsy (DSNB) as the preferred method for surgical staging among patients with invasive penile tumours and no palpable inguinal lymphadenopathy. This paper outlines the rationale behind this new recommendation and describes remaining challenges, as well as strategies for promoting DSNB worldwide. Main text DSNB offers high diagnostic accuracy with the lowest postoperative complications compared to open or minimally invasive inguinal lymph node dissection (ILND), prompting its preference in the new guidelines. Nevertheless, despite its advantages, there are challenges hampering the widespread adoption of DSNB. This includes the false-negative rate associated with DSNB and the potential negative impact on patient outcome. To address this issue, improvements should be made in several areas, including refining the timing and interpretation of the lymphoscintigraphy and the single photon emission computed tomography/computed tomography images. In addition, the quantity of tracer employed and choice of the injection site for the radiopharmaceutical should be optimised. Finally, limiting the removal of nodes without tracer activity during surgery may help minimise complication rates. Conclusion Over the years, DSNB has evolved significantly, related to the dedicated efforts and innovations in nuclear medicine and subsequent clinical studies validating its efficacy. It is now strongly recommended for surgical staging among selected penile cancer patients. To optimise DSNB further, multidisciplinary collaborative research is required to improve SN identification for better diagnostic accuracy and fewer complications.

You have accessJournal of UrologyPenile & Testicular Cancer II (MP61)1 May 2024MP61-12 DOES THE "10% RULE" APPLY TO SENTINEL NODE BIOPSIES FOR PENILE SQUAMOUS CELL CARCINOMA? Sylvia Yan, Benjamin Ayres, Holly Ni Raghallaigh, Rachel Oliver, and Nicholas Watkin Sylvia YanSylvia Yan , Benjamin AyresBenjamin Ayres , Holly Ni RaghallaighHolly Ni Raghallaigh , Rachel OliverRachel Oliver , and Nicholas WatkinNicholas Watkin View All Author Informationhttps://doi.org/10.1097/01.JU.0001009536.58867.87.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inguinal dynamic sentinel biopsies (DSNB) is a minimally invasive way of staging squamous cell carcinoma of the penis (pSCC) for patients with clinically node negative (cN0) disease. The number of nodes removed positively correlates with increased morbidity as described in breast cancer and is clinically evident in our practice. The "10% rule" has been used in breast cancer whereby radioactive nodes are excised until a background count of <10% of total radioactivity is seen, and no further nodes are then removed. This assumes that low count nodes are not positive. Based on this, we conducted a study of DSNB, evaluating positivity and radioactive count. METHODS: A prospectively collected database of all patients treated at our tertiary referral centre was reviewed. All patients with cN0 pSCC who underwent DSNB staging between November 2020 and December 2022 were included. Our practice to date has been to remove all radioactive or blue nodes down to a background radioactivity count of <100MBq (1–3% of total nodal count). RESULTS: 298 inguinal basins were staged by DSNB within the 2-year period. Median follow up 15.5 months (IQR 9–22.3). 30 (10%) of the basins were positive for metastatic spread of SCC. 87% (n=26) of the 30 positive basins had a positive node that had a radioactive count of >20% of total activity. In 7% (n=2), the count of the positive node was between 10–20% of the total activity. In the remaining 2 cases, 1 groin had a positive node count between 1–10% of the total activity and the other had a positive node count of <1% of the total activity. This positive node was found to have a 7 mm metastatic deposit, not a fully involved node. Over the follow up period, no patients developed nodal recurrence. CONCLUSIONS: The results from our high-volume tertiary referral centre have indicated that in the majority (93%) of cases, applying the "10% rule" would accurately stage the inguinal basin. However, applying the 10% cut-off would have missed 7% of positive nodes. If the threshold were to be shifted to achieving a background radioactive count of 1%, the false negative rate would be 3%. Our data has shown that although the DSNB technique in penile cancer originated from experience in breast cancer, the "10% rule" may not necessarily translate and be applicable for our practice. Further research into identifying whether fewer lymph nodes can be safely excised during DSNBs is important to try and reduce morbidity of this staging procedure. Source of Funding: N/A © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e1016 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Sylvia Yan More articles by this author Benjamin Ayres More articles by this author Holly Ni Raghallaigh More articles by this author Rachel Oliver More articles by this author Nicholas Watkin More articles by this author Expand All Advertisement PDF downloadLoading ...

For patients with cN0 penile cancer, dynamic sentinel-node biopsy with preoperative inguinal ultrasound and fine-needle aspiration cytology has the lowest complication rates and high diagnostic accuracy. In comparison to open inguinal lymph node dissection (ILND), video-endoscopic ILND (with or without robot assistance) shows favourable results. Lymphatic-related complications are comparable between the open and video-endoscopic approaches.

BACKGROUND:Penile squamous cell carcinoma (PSCC) is characterised by stepwise lymphatic dissemination. Skip metastases (SkMs) are rare metastases in the corpus cavernosum or spongiosum without continuity to the primary tumour or its resection site. OBJECTIVE:To assess the distinct pattern of spread in SkM+ patients and the effect of SkM on prognosis. DESIGN, SETTING, AND PARTICIPANTS:We conducted a retrospective analysis of patients with SkM+ PSCC at ten high-volume international referral centres between January 2006 and May 2022. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:We evaluated histopathological data, primary lymph node (LN) staging, and metastatic spread. We included a cohort of patients matched for pT stage, LN status, and grade who did not have SkM (SkM-) to compare the SkM prognosis and predictive value for cancer-specific mortality (CSM). RESULTS AND LIMITATIONS:Among the 63 SkM+ patients who met our inclusion criteria, the SkM diagnosis was synchronous in 54.0% and metastases were mostly located in the corpus cavernosum. SkM was symptomatic in 14% of cases, was detected on imaging in 32%, and was found incidentally on pathological examination in 27%. Fifty-one patients (81%) presented with positive LNs and 28 (44%) developed distant metastases. Seven patients (11%) presented with or developed distant metastasis without displaying any LN involvement. The 2-yr cancer-specific survival estimates were 36% (95% confidence interval [CI] 25-52%) for SkM+ and 66% (95% CI 55-80%) for matched SkM- patients (p < 0.001). On multivariable Cox regression analysis, SkM presence was an independent predictor for higher CSM (hazard ratio 2.05, 95% CI 1.06-4,12; p = 0.03). CONCLUSIONS:PSCC-related SkM is associated with aggressive disease behaviour and poor survival outcomes. Palpation of the entire penile shaft is essential, and distant staging is recommended in patients suspected of having SkM owing to the tendency for distant metastatic spread. PATIENT SUMMARY:We investigated outcomes for patients with cancer of the penis who had metastases in the tissues responsible for erection. We found that metastases in this location were associated with poor prognosis, even in the absence of more typical spread of cancer via the lymph nodes.

Penile metastases are rare, with about 400 reported via case reports or small series. Under such circumstances coherent data about their behaviour may not be possible given vagaries of publication. For instance, one published meta‐analysis has proposed that malignant priapism contributes to worse survival, but this may be due to selection bias in published reports. We sought to evaluate clinical characteristics associated with survival in an international cohort of patients with metastases to the penis treated in major genitourinary cancer programmes.

Context: Penile cancer is a rare disease but has a significant impact on quality of life. Its incidence is increasing, so it is important to include new and relevant evidence in clinical practice guidelines.Objective: To provide a collaborative guideline that offers worldwide physician and patient guidance for the management of penile cancer. Evidence acquisition: Comprehensive literature searches were performed for each section topic. In addition, three systematic reviews were conducted. Levels of evidence were assessed, and a strength rating for each recommendation was assigned according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. Evidence synthesis: Penile cancer is a rare disease but its global incidence is increasing. Human papillomavirus (HPV) is the main risk factor for penile cancer and pathology should include an assessment of HPV status. The main aim of primary tumour treatment is complete tumour eradication, which has to be balanced against optimal organ preser-vation without compromising oncological control. Early detection and treatment of lymph node (LN) metastasis is the main determinant of survival. Surgical LN staging with sentinel node biopsy is recommended for patients with a high-risk (>= pT1b) tumour with cN0 status. While (inguinal) LN dissection remains the standard for node-positive disease, multimodal treatment is needed in patients with advanced disease. Owing to a lack of controlled trials and large series, the levels of evidence and grades of recommen-dation are low in comparison to those for more common diseases.Conclusions: This collaborative penile cancer guideline provides updated information on the diagnosis and treatment of penile cancer for use in clinical practice. Organ -preserving surgery should be offered for treatment of the primary tumour when feasible. Adequate and timely LN management remains a challenge, especially in advanced dis-ease stages. Referral to centres of expertise is recommended.Patient summary: Penile cancer is a rare disease that significantly impacts quality of life. While the disease can be cured in most cases without lymph node involvement, manage-ment of advanced disease remains challenging. Many unmet needs and unanswered questions remain, underlining the importance of research collaborations and centralisa-tion of penile cancer services. (c) 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.

CONTEXT:Lymph node (LN) involvement in penile cancer is associated with poor survival. Early diagnosis and management significantly impact survival, with multimodal treatment approaches often considered in advanced disease. OBJECTIVE:To assess the clinical effectiveness of treatment options available for the management of inguinal and pelvic lymphadenopathy in men with penile cancer. EVIDENCE ACQUISITION:EMBASE, MEDLINE, the Cochrane Database of Systematic Reviews, and other databases were searched from 1990 to July 2022. Randomised controlled trials (RCTs), nonrandomised comparative studies (NRCSs), and case series (CSs) were included. EVIDENCE SYNTHESIS:We identified 107 studies, involving 9582 patients from two RCTs, 28 NRCSs, and 77 CSs. The quality of evidence is considered poor. Surgery is the mainstay of LN disease management, with early inguinal LN dissection (ILND) associated with better outcomes. Videoendoscopic ILND may offer comparable survival outcomes to open ILND with lower wound-related morbidity. Ipsilateral pelvic LN dissection (PLND) in N2-3 cases improves overall survival in comparison to no pelvic surgery. Neoadjuvant chemotherapy in N2-3 disease showed a pathological complete response rate of 13% and an objective response rate of 51%. Adjuvant radiotherapy may benefit pN2-3 but not pN1 disease. Adjuvant chemoradiotherapy may provide a small survival benefit in N3 disease. Adjuvant radiotherapy and chemotherapy improve outcomes after PLND for pelvic LN metastases. CONCLUSIONS:Early LND improves survival in nodal disease in penile cancer. Multimodal treatments may provide additional benefit in pN2-3 cases; however, data are limited. Therefore, individualised management of patients with nodal disease should be discussed in a multidisciplinary team setting. PATIENT SUMMARY:Spread of penile cancer to the lymph nodes is best managed with surgery, which improves survival and has curative potential. Supplementary treatment, including the use of chemotherapy and/or radiotherapy, may further improve survival in advanced disease. Patients with penile cancer with lymph node involvement should be treated by a multidisciplinary team.

Purpose of review Penile sparing surgery (PSS) is considered the standard of care in penile cancer where appropriate, as preservation of the penis may enable the patient to maintain urinary and sexual function. This review will focus on the latest developments over the past two years. Recent findings In this review, we discuss the latest findings in oncological outcomes in PSS, specifically glansectomy. We also introduce technology that may be useful in improving the precision of surgical resection margins in PSS. Finally, we consider the value of patient-reported outcome measures (PROMs) and consider how research in this area can be improved. Summary A recent study has found a correlation between local recurrences (LR) and worse overall and cancer-specific survival in glansectomy, which challenges the belief that LR do not confer worse oncological outcomes. Despite numerous studies evaluating PROMs in penile cancer/PSS, few of these studies provide quality evidence of the ‘supportive care needs’. A shift in research is required to identify those men at most risk of distress and to identify ways to support men diagnosed with penile cancer.

Context:The primary lesion in penile cancer is managed by surgery or radiation. Surgical options include penile-sparing surgery, amputative surgery, laser excision, and Moh's micrographic surgery. Radiation is applied as external beam radiotherapy (EBRT) and brachytherapy. The treatment aims to completely remove the primary lesion and preserve a sufficient functional penile stump.Objective:To assess whether the 5-yr recurrence-free rate and other outcomes, such as sexual function, quality of life, urination, and penile preserving length, vary between various treatment options.Evidence acquisition:The EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane HTA, DARE, HEED), Google Scholar, and ClinicalTrials.gov were searched for publications from 1990 through May 2021. Randomized controlled trials, nonrandomized comparative studies (NRCSs), and case series (CSs) were included.Evidence synthesis:The systematic review included 88 studies, involving 9578 men from 16 NRCSs and 72 CSs. The cumulative mean 5-yr recurrence-free rates were 82.0% for penile-sparing surgery, 83.9% for amputative surgery, 78.6% for brachytherapy, 55.2% for EBRT, 69.4% for lasers, and 88.2% for Moh's micrographic surgery, as reported from CSs, and 76.7% for penile-sparing surgery and 93.3% for amputative surgery, as reported from NRCSs. Penile surgery affects sexual function, but amputative surgery causes more appearance concerns. After brachytherapy, 25% of patients reported sexual dysfunction. Both penile-sparing surgery and amputative surgery affect all aspects of psychosocial well-being.Conclusions:Despite the poor quality of evidence, data suggest that penile-sparing surgery is not inferior to amputative surgery in terms of recurrence rates in selected patients. Based on the available information, however, broadly applicable recommendations cannot be made; appropriate patient selection accounts for the relative success of all the available methods.Patient summary:We reviewed the evidence of various techniques to treat penile tumor and assessed their effectiveness in oncologic control and their functional outcomes. Penile-sparing as well as amputative surgery is an effective treatment option, but amputative surgery has a negative impact on sexual function. Penile-sparing surgery and radiotherapy are associated with a higher risk of local recurrence, but preserve sexual function and quality of life better. Laser and Moh's micrographic surgery could be used for smaller lesions.